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APPLICATION FOR SANITATION PERMIT Permit No. -- ✓''" f (Complete in Duplicate) Date Issued . /--r'_ - � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This:.application 'is_made yin compliance with County Ordinance)No-. 55549. f '`� � `�r--0-,-/— 0 r' ,` l/ f 0 !` JOB ADDRESS AN TION__ -_ .._=�,!�''i'u'�---- -- ._!--------= -' �� f Owner's Name-✓`!� �''�' --------------•------------ �----------------------- Phone__'_ �' Address. 1'_. _ L--_-_!/if y _ ------------------------------------------------------------- -------- ---------- ------- Contractor's Name `- �'r -------------------------------------- Phone - r ---------------------------------------------------- -- Installation will serve:. Residence ❑ Apartment House [-] Commercial E] Trailer Court F] Motel E] Other ❑� � Number of living units:. -- Number of bedroomsa.�,.__ Number of baths__ Lot s1ze.___5_' ---------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EV Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well _�rct _Distanceafro o�atign---d depth__-aterial Ca aci'� No. of compartments----- ----------------- Ar --- ------ Size_ qz P tY �* Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_-________---_-__ ") ❑ Number of lines-----------------------------------Length of each line----------------------;------.Width of french---------------------------------- Type of filter maferiai-------------------------Depth of filter materia ------------------------- Total length__---__________________--_____________j Seepage Pit: Distance to nearest well�r�_— -_Distance from fou�rdation____r)_____________ to i jo nearest lot line________________ ' Number of pits--- --/ __Lining material. - --� ;Size: Diameter____- De th_.__- - - p -- -- Cesspool: Distance from nearest well----------------- El from foundation___________________Lining material----------------.-________-___--____. ❑ Size: Diameter--------------------------------------Depth---------------------.- ------------- -----------Liquid Capacity----------------------------:gals Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El _____-_--_--_______________-_--------❑ Distance to nearest lot line------------------- ------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):- � t�'------------------------------------------------------------------------------------------------- ----------- --------------------------------------- ------------- �h -----------------------------------------------------------------------------------------•------------------------------ --------------) ------------ ------ ----- ------------ ------------------------------------------------------------------------------------------------ - �. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State/". and4blev-and regulations of the San Joaquin Local Health District. (Signed)-- 1�� --------------- e---- -- (Owner and/or Contractor) Ll '' ----------------- By:----- ------- r' := � � (Plot plan, showing size of to go n of step in r ation to wells, buildings, etc., can be placed on reverse side FOR DEPARTMENT USE ONLY v APPLICATION ACCEPTED B ---------------------- DATE_ --- ------------------ --------------------------- REVIEWEDBY---------------------------- DATE-- ` -------I------------- BUILDINGPERMIT ISSUED-------------------------------------- -------------------------------------------------------------- DATE r Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------- -- r r FINAL INSPECTION BY:--------- - Date------------------------------ --------------------- - ----------------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American 'Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street 4 Stockton, California Lodi, California Manteca, California Tracy, California F ES-9-2M B-51 Revised W-2100